Background of the companies 4 companies are involved in the Hillsborough disaster (event) happened in 1989. They are the Sheffield Wednesday Football Club (SWFC), Liverpool Football Club (FC), Nottingham Forest FC and the Football Association (FA).SWFC is the owner of Hillsborough stadium, which opened in 1899. In 1913, the stadium constructed a new main stand and expand the terraces. A new North Stand was built with a cantilever roof in the early 1960s and improvements were made to the Leppings Lane Ends and North West Corner in the subsequent years.
In 1986, a roof over the Kop was constructed. On 15 April 1989, the match between Liverpool and Nottingham Forest Clubs for FA Cup semi-final that was organized by the Football Association was held at Hillsborough stadium. However, a disaster has occurred at the west stand Leppings Lane end, specifically at pens 3 and 4. Due to the poor management of overcrowding by SWFC, Sheffield City Council and South Yorkshire Police (SYP), the tunnel collapsed to pens 3 and 4, resulting in 96 died due to crushing and approximately 730 people injured.
Before the 1989 Hillsborough disaster, the FA Cup semi-final between Tottenham Hotspur and Wolverhampton Wanderers took place and major congestion occurred at the Leppings Lane turnstiles and crushing on the confined outercourse at Hillsborough stadium in 1981. Although exit gate C is opened to relieve the crush, 38 supporters still suffered from injuries like stitches and broken legs. (2) Introduction SWFC has allocated 376 stewards, gatemen and turnstile operators for duty on 15 April 1989. They were briefed by police Inspectors regarding the match and were in charge of the ground. The club’s control room and the stewards can communicate through the VHF radio. Closed-circuit television (CCTV) was installed, and the control room will be authorized to view the turnstiles around the ground.Turnstiles were installed to control the flow of supporters entering the ground and pens. A computerized counting system was incorporated in the turnstiles to monitor the number of spectators passing through the turnstiles section by section. However, the system could not track the distributions of spectators on the terracing, thus no warning is given when one pen was full beyond the safe capacity. Alerts will only be activated if the total of any section was within 15% of its allowed capacity. Furthermore, Sun Alliance is the insurer of SWFC which provides risk management resource to help the club to identify and mitigate risk so that negative consequences to operations, facilities and employees will be reduced.In June 1986, the police asked for the crash barrier nearest to pens 3 and 4 to be removed as it was deemed to obstruct the effectiveness of emergency evacuation through the tunnel. Dr. Eastwood- the consultant of SWFC accepted the police perspective. A meeting was held on 7 August 1986 onsite and the Officer Working Party approved the proposal. Mr. Bownes who represents the Sheffield City Council was responsible for issuing the Safety Certificates as of 1 April 1986. South Yorkshire Police (SYP) in charge by Chief Superintendent David Duckenfield was required to secure the safety of the stadium, regulate the event flow by managing the crowds and oversees the event. A total of 1,122 police was positioned for the match, which makes up 38% of the total South Yorkshire force. The police force was split into serial comprising 8 to 10 Constables, a Sergeant, and an Inspector. The serial was assigned to duties at different stations in 3 phases: before, during and after the match. The police force has to follow an Operational Order that was closely related to the order set for the 1988 semi-final and take into consideration the force’s Standing Instruction for the Policing of Football Grounds’. The order explained the responsibilities of each serial at each phase and it will be conveyed through an oral briefing before and during the day of the match. The center police control is situated at a control box located at the south-west corner of the ground as there was a window commanding view across the pitch and straight along the line of the west perimeter fence. Superintendent Murray was in control of the box and play as an advisor to Mr. Duckenfield. Sergeant Goddard was operating the radios, Police Constable (PC) Ryan worked on the telephone and public address systems, and PC Bichard controlled the police CCTV system. After the occurrence of the Hillsborough disaster, PC Bichard has requested for fire service for hydraulic cutting equipment for rescuing. The fire brigades also provide oxygen cylinders and resuscitation equipment. Station Officer Fletcher set up a casualty clearing area under the police box and fireman contribute by carrying victims and performing first aid on the pitch. South Yorkshire Metropolitan Ambulance Service (SYMAS) has been allocated to the north stand close to the gymnasium and the south stand near the players’ tunnel. There was a total of 2 ambulances, one situated outside the ground and another on standby. During the Hillsborough disaster, 31 SYMAS and 11 ambulances from neighboring authorities were activated for rescue and 172 casualties were sent to Northern General Hospital and Royal Hallamshire Hospital by 4.30pm. (3) Observation and Analysis On 15 April 1989, thousands of Liverpool supporters are gathered outside the ground at the Leppings Lane End between 2.30pm- 2.40pm. The turnstiles were decrepit and mean admission to the ground is slow. At 2.50pm, pens 3 and 4 on the stand’s lower terrace was full and there was a rise in pressure due to the increasing number of supporters entering. Although the official combined capacity was 2,200, it is estimated that more than 3,000 supporters were allocated to the center pens. At 2.52pm, exit Gate C was opened to ease the crush outside the ground and approximately 2,000 supporters went to the ground through the tunnel directly led to pens 3 and 4. At 2.59pm, the inflow of crowd causes severe crushing in pens 3 and 4 and supporters began to climb over the perimeter fences to escape to pens 2 and 5. Five minutes after the match started at 3 pm, a crash barrier inside pen 3 collapse, resulting supporters to fall over. The disaster caused 730 people injured and 96 fatally. (4) EvaluationThe investigation has proposed 6 key mistakes leading to the 1989 Hillsborough disaster. Firstly, SWFC only removed 2 spans of the barrier and leaving one span in pen 4 despite the police approach in June 1986. The span is identified as an obstruction that slows down the flow of supporters and disrupts the effectiveness of evacuation. Thus, the defects of the stadium contributed to the disaster. Next, there was an error in the safety certificate distributed to the stadium. In May 1988, an Officer Working Party stated that the stadium had no significant defects. Although Leppings Lane terrace underwent alteration, there is no revised in the safety certificate. Mr. Bownes, on behalf of Sheffield City Council, proceed in issuing the Safety Certificate which creates a false impression that the stadium is safe. Thirdly, no full attendance was achieved on a planning meeting as SYMAS and the fire service was absent. Hence, it proposed that some department were unaware of the briefing information and their individual responsibilities which leads to the delay of evacuation. The meeting was held less than a month before the match which suggests the insufficient time for planning. Moreover, the SYP Operational Order focuses on the control and regulation of the crowd with no appropriate reference to crowd safety and evacuation of terraces. Hence, SYP was prioritizing crowd control over crowd safety and unfamiliar with the evacuation process. Fourthly, there was a failure to prevent congestion due to the lack of police cordon, as admitted by Chief Superintendent David Duckenfield. No measures are implemented to keep the queues in order and regulating the entry of supporters to the ground. Police closed the turnstiles to separate the Liverpool and Nottingham Forest fans apart. The decision and the design of the approach to the stand make the congestion worse. Moreover, no contingency plans were created to deal with the sudden arrival of a large crowd due to the road closure in the area. Fifthly, Mr. Duckenfield has limited experience of policing football matches and causing him to make inaccurate decisions during the Hillsborough event. At 1452 hour, Mr. Duckenfield gave the order of opening gate C with the objective of relieving the crowd pressure. As such, 2000 supporters passed through the gate and majority headed straight to the tunnel towards the central pens 3 and 4. This portrays the direct cause of death of the 96 people in the Hillsborough disaster.Furthermore, Mr. Duckenfield decided not to delay the kick-off even though TV monitors in the control room showed that the numbers at the Leppings Lane end were expanding. Due to the negligence in alleviating the crowd frustration and anxiety to the ground, it leads to the expense of crowd safety because supporters were eager to rush into the ground, resulting in congestion. Mr. Duckenfield decided not to broadcast information to the public through the public address system as he feared that the crowd may turn hostile. Therefore, supporters were only aware of the situation at 3.56pm through Mr. Kenny Dalglish. Lastly, there was a delay in emergency response. 42 ambulances were held up outside the ground and only 2 ambulances reach the Leppings Lane because crowd trouble’ was reported. Of the 96 victims who die, only 14 were admitted to the hospital, suggesting that many people did not manage to get treatment. Senior Ambulance Officer Eason, who was on the ground with the ambulance failed to asses the situation in the stadium and miss the earliest opportunity to declare a disaster. He only declares the major incident at 3.22pm when it occurred at 2.59pm, slowing down the emergency response. Officer Eason’s radio had been faulty during duty but did not alert the nearby hospitals because he assumed that the ambulance control room will do so, which suggest a lack of communication.Overall, there was a delay in the escalation actions, life safety actions, environmental protection actions, asset protection actions and also ineffective communication actions. Hence, this results in the ineffective evacuation process. (5) RecommendationsSix recommendations will be discussed to counter the evaluation. Firstly, an immediate review of each Safety Certificate is required by the responsible local authority through inspection of the stadium on an annual basis. It is to ensure that the operative conditions of the Certificate are fulfilled and to substitute any condition shown to be necessary as a matter of urgency. The stadium should be obligated to renew the Certificates annually to guarantee safety and rules are met.The local authority should set up an Advisory group consisting of their own employee, representatives of police, fire and ambulance services and building authority to comprehend with matters concerning with crowd safety and should visit the stadium ground regularly and attend matches. Its resolution should be documented and produce report frequently for consideration by the local authorities. Secondly, threat monitoring responsibilities should be handled by specific departments based on their expertise. For example, the facilities department monitors the utility system and the IT department keeps track of the data center. The stadium should also adopt the Incident Command System as it is a set of policies and procedures implemented to improve emergency response operations. It includes terminology, hierarchy, and methodology. The common framework allows people to work together effectively due to the coordination of public and private sector efforts. The Chain-of-Command needs to be clear, and an Incident Commander should be appointed to take charge of the Emergency Response Team. Incident Commander will be responsible for command and control of all aspects of a crisis. Thirdly, the stadium should coordinate with the Emergency Management Agencies to synchronize comprehensive emergency management plans. Personnel involved in the event should participate in the National Response Framework Training’ to better prepare them to effectively and efficiently respond to an emergency. Attending the planning meeting for an event should be made compulsory to every department and the meeting should be held at least 3 months before the event. Fourthly, the police force should liaise with the management of each football club and local authority to address concerns of the safety and control of crowds. Furthermore, all officers on duty should be briefed and alert them on the importance of preventing overcrowding. The Operational Order should provide precise steps to remedy the overcrowding issue. It should allow the police to handle the arrival and departure of the spectators to a match. The order should offer adequate reserves for the deployment of officers to be made inside and outside the ground. Additionally, police officers in charge of the control room are supposed to monitor the crowd through data, thus they need to be experienced in interpreting and use of these data. Next, the police control room should acquire sufficient operators to permit all radio transmissions to be received, evaluated and answered. The radio system should be prioritizing the operators in the control room and they should be given the capacity to override others using the same channel. The additional channel should be utilized to overcome the overcrowding in airwaves. A separate system of landlines with telephone links between the control room and the ground are needed to complement radio communication. Moreover, police officers should create a simple code of hand signals to specify to control room the existence of emergencies or requirements.Additionally, notification procedures should be set in place. Detected crisis events need to be reported. The police force should be the central point of contact receiving crisis information, investigating, and communicating the information as necessary. Lastly, it is crucial to improve the coordination of emergency services. The police, ambulance and fire services should maintain regular liaison regarding crowd safety. The police should update the ambulance and fire services of the full details about the event, including its venue, it’s timing, the number of spectators predicted, and potential difficulties related to the movement of the crowd. Moreover, contingency plans for the arrival of emergency vehicles from all three services should be implemented. It should contain routes of access, rendezvous points, and accessibility within the ground. Police officers at the entrances to the ground should be informed of the contingency plans and when, where and such services are needed. This will prevent slow emergency response and the risk of being delayed.